Acute Coronary SyndromeAcute Coronary Syndrome

Sofiya Lypovetska, MD PhDSofiya Lypovetska, MD PhDTernopil State Medical UniversityTernopil State Medical University

Ukraine Ukraine

Scope of Problem Scope of Problem

CHD single leading cause of CHD single leading cause of death in United Statesdeath in United States

1,200,000 new & recurrent 1,200,000 new & recurrent coronary attacks per year coronary attacks per year

38% of those who with 38% of those who with coronary attack die within a coronary attack die within a year of having ityear of having it

Annual cost > $300 billionAnnual cost > $300 billion

Expanding Risk FactorsExpanding Risk Factors

SmokingSmokingHypertensionHypertensionDiabetes MellitusDiabetes MellitusDyslipidemiaDyslipidemia– Low HDL < 40Low HDL < 40– Elevated LDL / TGElevated LDL / TG

Family History—event Family History—event in first degree relative in first degree relative >>55 male/65 female55 male/65 female

Age-- Age-- >> 45 for 45 for male/55 for femalemale/55 for femaleChronic Kidney Chronic Kidney DiseaseDiseaseLack of regular Lack of regular physical activityphysical activityObesityObesityLack of Etoh intakeLack of Etoh intakeLack of diet rich in Lack of diet rich in fruit, veggies, fiberfruit, veggies, fiber

• Distruption of coronary artery plaque -> platelet activation/aggregation /activation of coagulation cascade -> endothelial vasoconstriction ->intraluminal thrombus/embolisation -> obstruction -> ACS

• Severity of coronary vessel obstruction & extent of myocardium involved determines characteristics of clinical presentation

Pathophysiology of ACSPathophysiology of ACS

Acute Coronary SyndromesAcute Coronary Syndromes

Similar pathophysiologySimilar pathophysiology

Similar presentation and Similar presentation and early management rulesearly management rules

STEMI requires evaluation STEMI requires evaluation for acute reperfusion for acute reperfusion interventionintervention

Unstable AnginaUnstable Angina

Non-ST-Segment Non-ST-Segment Elevation MI Elevation MI (NSTEMI)(NSTEMI)

ST-Segment ST-Segment Elevation MI Elevation MI (STEMI)(STEMI)

Diagnosis of Acute MIDiagnosis of Acute MI STEMI / NSTEMI STEMI / NSTEMI

At least 2 of the At least 2 of the followingfollowing

Ischemic symptomsIschemic symptomsDiagnostic ECG Diagnostic ECG changeschangesSerum cardiac Serum cardiac marker elevationsmarker elevations

Diagnosis of AnginaDiagnosis of Angina

Typical angina—All three of the followingTypical angina—All three of the followingSubsternal chest discomfortSubsternal chest discomfortOnset with exertion or emotional stressOnset with exertion or emotional stressRelief with rest or nitroglycerinRelief with rest or nitroglycerin

Atypical anginaAtypical angina2 of the above criteria2 of the above criteria

Noncardiac chest painNoncardiac chest pain1 of the above1 of the above

CHARACTERISTICS OF TYPICAL ANGINAL CHEST PAIN CHARACTERISTICS OF TYPICAL ANGINAL CHEST PAIN (ADAPTED FROM ROSEN’S, EMERGENCY MEDICINE)(ADAPTED FROM ROSEN’S, EMERGENCY MEDICINE)

CHARACTERISTICCHARACTERISTIC SUGGESTIVE OF ANGINASUGGESTIVE OF ANGINA LESS SUGGESTIVE OF LESS SUGGESTIVE OF ANGINAANGINA

TYPE OF PAINTYPE OF PAIN DULL DULL PRESSURE/CRUSHING PRESSURE/CRUSHING PAINPAIN

SHARP/STABBINGSHARP/STABBING

DURATIONDURATION 2-5 MIN, <20 MIN2-5 MIN, <20 MIN SECONDSTO SECONDSTO HOURS/CONTINUOUSHOURS/CONTINUOUS

ONSETONSET GRADUALGRADUAL RAPIDRAPID

LOCATION/CHEST WALL LOCATION/CHEST WALL TENDERNESSTENDERNESS

SUBSTERNAL, NOT SUBSTERNAL, NOT TENDER TO PALP.TENDER TO PALP.

LATERAL CHEST LATERAL CHEST WALL/TENDER TO PALP.WALL/TENDER TO PALP.

REPRODUCIBALITYREPRODUCIBALITY WITH WITH EXERTION/ACTIVITYEXERTION/ACTIVITY

WITH WITH BREATHING/MOVINGBREATHING/MOVING

AUTONOMIC SYMPTOMSAUTONOMIC SYMPTOMS PRESENT USUALLYPRESENT USUALLY ABSENTABSENT

ATYPICAL PAINATYPICAL PAIN

RISK FACTORS FOR DEVELOPING ATYPICAL PAIN:RISK FACTORS FOR DEVELOPING ATYPICAL PAIN:Diabetes, females, non white patients, elderly, dementia, no prior history of Diabetes, females, non white patients, elderly, dementia, no prior history of MIMIATYPICAL SYMPTOMS:ATYPICAL SYMPTOMS:GIT symptomsGIT symptomsSyncopeSyncopeSOBSOBPleuritic/positional painPleuritic/positional painChest wall tendernessChest wall tendernessNo chest pain/symptomsNo chest pain/symptoms

NRMI 2 STUDYNRMI 2 STUDY – MI without chest pain -> increased risk of death (23% vs – MI without chest pain -> increased risk of death (23% vs 9%)9%)More complications – hypotension,heart failure, strokeMore complications – hypotension,heart failure, strokeDelayed ED presentation, delayed interventionDelayed ED presentation, delayed intervention

Diagnosis of Unstable AnginaDiagnosis of Unstable Angina

Patients with typical angina - An episode of angina Patients with typical angina - An episode of angina Increased in severity or durationIncreased in severity or durationHas onset at rest or at a low level of exertionHas onset at rest or at a low level of exertionUnrelieved by the amount of nitroglycerin or rest that Unrelieved by the amount of nitroglycerin or rest that had previously relieved the painhad previously relieved the pain

Patients not known to have typical anginaPatients not known to have typical anginaFirst episode with usual activity or at rest within the First episode with usual activity or at rest within the previous two weeksprevious two weeksProlonged pain at restProlonged pain at rest

Unstable Unstable AnginaAngina STEMISTEMI NSTEMINSTEMI

Non occlusive thrombus

Non specific ECG

Normal cardiac enzymes

Occluding thrombus sufficient to cause tissue damage & mild myocardial necrosis

ST depression +/- T wave inversion on ECG

Elevated cardiac enzymes

Complete thrombus occlusion

ST elevations on ECG or new LBBB

Elevated cardiac enzymes

More severe symptoms

Acute ManagementAcute Management

Initial evaluation & Initial evaluation & stabilizationstabilization

Efficient risk Efficient risk stratificationstratification

Focused cardiac Focused cardiac carecare

EvaluationEvaluationEfficient & direct history Efficient & direct history Initiate stabilization interventionsInitiate stabilization interventions

Plan for moving rapidly to Plan for moving rapidly to indicated cardiac careindicated cardiac care

Directed Therapies are

Time Sensitive!

Occurs Occurs simultaneouslsimultaneousl

yy

Chest pain suggestive of ischemiaChest pain suggestive of ischemia

– 12 lead ECG12 lead ECG– Obtain initial Obtain initial

cardiac enzymescardiac enzymes– electrolytes, cbc electrolytes, cbc

lipids, bun/cr, lipids, bun/cr, glucose, coagsglucose, coags

– CXRCXR

Immediate assessment within 10 Minutes

– Establish Establish diagnosisdiagnosis

– Read ECGRead ECG– Identify Identify

complicationscomplications– Assess for Assess for

reperfusionreperfusion

Initial Initial labslabs

and testsand testsEmergent Emergent

carecareHistory History

& & PhysicalPhysical

– IV accessIV access– Cardiac Cardiac

monitoringmonitoring– OxygenOxygen– AspirinAspirin– NitratesNitrates

Focused HistoryFocused HistoryAid in diagnosis and Aid in diagnosis and rule out other causesrule out other causes

– Palliative/Provocative Palliative/Provocative factorsfactors

– Quality of discomfortQuality of discomfort– RadiationRadiation– Symptoms associated Symptoms associated

with discomfortwith discomfort– Cardiac risk factorsCardiac risk factors– Past medical history -Past medical history -

especially cardiacespecially cardiac

Reperfusion Reperfusion questionsquestions

– Timing of Timing of presentationpresentation

– ECG c/w STEMI ECG c/w STEMI – Contraindication to Contraindication to

fibrinolysisfibrinolysis– Degree of STEMI riskDegree of STEMI risk

Targeted PhysicalTargeted PhysicalRecognize factors that Recognize factors that increase riskincrease risk

HypotensionHypotensionTachycardiaTachycardiaPulmonary rales, JVD, Pulmonary rales, JVD, pulmonary edema,pulmonary edema,New murmurs/heart New murmurs/heart soundssoundsDiminished peripheral Diminished peripheral pulsespulsesSigns of strokeSigns of stroke

ExaminationExamination– VitalsVitals– Cardiovascular Cardiovascular

systemsystem– Respiratory Respiratory

systemsystem– AbdomenAbdomen– Neurological Neurological

statusstatus

ECG assessmentECG assessment

ST Elevation or new LBBBST Elevation or new LBBBSTEMISTEMI

Non-specific ECGNon-specific ECGUnstable AnginaUnstable Angina

ST Depression or dynamicST Depression or dynamicT wave inversionsT wave inversions

NSTEMINSTEMI

Normal or non-diagnostic EKGNormal or non-diagnostic EKG

ST Depression or Dynamic T wave ST Depression or Dynamic T wave InversionsInversions

ST-Segment Elevation MIST-Segment Elevation MI

New LBBBNew LBBB

QRS > 0.12 secL Axis deviationProminent S wave V1-V3Prominent R wave 1, aVL, V5-V6 with t-wave inversion

Cardiac markersCardiac markersTroponin ( T, I)Troponin ( T, I)

– Very specific and more Very specific and more sensitive than CKsensitive than CK

– Rises 4-8 hours after Rises 4-8 hours after injuryinjury

– May remain elevated May remain elevated for up to two weeksfor up to two weeks

– Can provide Can provide prognostic informationprognostic information

– Troponin T may be Troponin T may be elevated with renal dz, elevated with renal dz, poly/dermatomyositispoly/dermatomyositis

CK-MB isoenzymeCK-MB isoenzyme

– Rises 4-6 hours after Rises 4-6 hours after injury and peaks at 24 injury and peaks at 24 hourshours

– Remains elevated 36-48 Remains elevated 36-48 hourshours

– Positive if CK/MB > 5% of Positive if CK/MB > 5% of total CK and 2 times total CK and 2 times normalnormal

– Elevation can be Elevation can be predictive of mortalitypredictive of mortality

– False positives with False positives with exercise, trauma, muscle exercise, trauma, muscle dz, DM, PEdz, DM, PE

Prognosis with TroponinPrognosis with Troponin

1.01.7

3.4 3.7

6.0

7.5

012345678

0 to <0.4 0.4 to <1.0 1.0 to <2.0 2.0 to <5.0 5.0 to <9.0 9.0

Cardiac troponin I (ng/ml)

Mor

talit

y at

42

Day

s

831 174 148 134 50 67

%%

%%

%

%

Risk StratificationRisk Stratification

UA or NSTEMIUA or NSTEMI- Evaluate for Invasive - Evaluate for Invasive

vs. conservative vs. conservative treatmenttreatment

- Directed medical - Directed medical therapytherapy

Based on initialBased on initialEvaluation, ECG, andEvaluation, ECG, and

Cardiac markersCardiac markers

- Assess for - Assess for reperfusionreperfusion

- Select & implement - Select & implement reperfusion therapyreperfusion therapy

- Directed medical - Directed medical therapytherapy

STEMI Patient?

YESYES NONO

Cardiac Care Goals Cardiac Care Goals

Decrease amount of myocardial Decrease amount of myocardial necrosisnecrosisPreserve LV functionPreserve LV functionPrevent major adverse cardiac events Prevent major adverse cardiac events Treat life threatening complicationsTreat life threatening complications

STEMI cardiac care STEMI cardiac care STEP 1STEP 1: Assessment: Assessment– Time since onset of symptomsTime since onset of symptoms

– 90 min for PCI / 12 hours for fibrinolysis90 min for PCI / 12 hours for fibrinolysis

– Is this high risk STEMI?Is this high risk STEMI?– KILLIP classificationKILLIP classification– If higher risk may manage with more invasive rxIf higher risk may manage with more invasive rx

– Determine if fibrinolysis candidateDetermine if fibrinolysis candidate– Meets criteria with no contraindicationsMeets criteria with no contraindications

– Determine if PCI candidateDetermine if PCI candidate– Based on availability and time to balloon rxBased on availability and time to balloon rx

Fibrinolysis indicationsFibrinolysis indications

ST segment elevation >1mm in two ST segment elevation >1mm in two contiguous leadscontiguous leadsNew LBBBNew LBBBSymptoms consistent with ischemiaSymptoms consistent with ischemiaSymptom onset less than 12 hrs prior to Symptom onset less than 12 hrs prior to presentationpresentation

Absolute contraindications for fibrinolysis Absolute contraindications for fibrinolysis therapy in patients with acute STEMItherapy in patients with acute STEMI

Any prior ICHKnown structural cerebral vascular lesion (e.g., AVM) Known malignant intracranial neoplasm (primary or metastatic)Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hoursSuspected aortic dissectionActive bleeding or bleeding diathesis (excluding menses)Significant closed-head or facial trauma within 3 months

Relative contraindications for fibrinolysis Relative contraindications for fibrinolysis therapy in patients with acute STEMItherapy in patients with acute STEMI

History of chronic, severe, poorly controlled hypertensionSevere uncontrolled hypertension on presentation (SBP greater than 180 mm Hg or DBP greater than 110 mmHg) History of prior ischemic stroke greater than 3 months, dementia, or known intracranial pathology not covered in contraindicationsTraumatic or prolonged (greater than 10 minutes) CPR or major surgery (less than 3 weeks)Recent (within 2-4 weeks) internal bleedingNoncompressible vascular puncturesFor streptokinase/anistreplase: prior exposure (more than 5 days ago) or prior allergic reaction to these agentsPregnancyActive peptic ulcerCurrent use of anticoagulants: the higher the INR, the higher the risk of bleeding

STEMI cardiac careSTEMI cardiac careSTEP 2STEP 2: Determine preferred reperfusion strategy: Determine preferred reperfusion strategy

FibrinolysisFibrinolysis preferred if: preferred if:– <<3 hours from onset3 hours from onset– PCI not available/delayedPCI not available/delayed

door to balloon > door to balloon > 90min90mindoor to balloon minus door to balloon minus door to needle > 1hrdoor to needle > 1hr

– Door to needle goal Door to needle goal <30min<30min

– No contraindicationsNo contraindications

PCIPCI preferred if:preferred if:– PCI availablePCI available– Door to balloon < 90minDoor to balloon < 90min– Door to balloon minus Door to balloon minus

door to needle < 1hrdoor to needle < 1hr– Fibrinolysis Fibrinolysis

contraindicationscontraindications– Late Presentation > 3 hrLate Presentation > 3 hr– High risk STEMIHigh risk STEMI

Killup 3 or higherKillup 3 or higher– STEMI dx in doubtSTEMI dx in doubt

Medical TherapyMedical TherapyMONA + BAHMONA + BAH

MorphineMorphine (class I, level C)(class I, level C)AnalgesiaAnalgesiaReduce pain/anxiety—decrease sympathetic tone, Reduce pain/anxiety—decrease sympathetic tone, systemic vascular resistance and oxygen demandsystemic vascular resistance and oxygen demandCareful with hypotension, hypovolemia, respiratory Careful with hypotension, hypovolemia, respiratory depressiondepression

OxygenOxygen (2-4 liters/minute) (class I, level C)(2-4 liters/minute) (class I, level C)Up to 70% of ACS patient demonstrate hypoxemiaUp to 70% of ACS patient demonstrate hypoxemiaMay limit ischemic myocardial damage by May limit ischemic myocardial damage by increasing oxygen delivery/reduce ST elevationincreasing oxygen delivery/reduce ST elevation

NitroglycerinNitroglycerin (class I, level B)(class I, level B)Analgesia—titrate infusion to keep patient pain freeAnalgesia—titrate infusion to keep patient pain freeDilates coronary vessels—increase blood flowDilates coronary vessels—increase blood flowReduces systemic vascular resistance and preloadReduces systemic vascular resistance and preloadCareful with recent ED meds, hypotension, Careful with recent ED meds, hypotension, bradycardia, tachycardia, RV infarctionbradycardia, tachycardia, RV infarction

AspirinAspirin (160-325mg chewed & swallowed) (class I, (160-325mg chewed & swallowed) (class I, level A)level A)

Irreversible inhibition of platelet aggregationIrreversible inhibition of platelet aggregationStabilize plaque and arrest thrombusStabilize plaque and arrest thrombusReduce mortality in patients with STEMIReduce mortality in patients with STEMICareful with active PUD, hypersensitivity, bleeding Careful with active PUD, hypersensitivity, bleeding disordersdisorders

Beta-BlockersBeta-Blockers (class I, level A)(class I, level A)14% reduction in mortality risk at 7 days at 23% long 14% reduction in mortality risk at 7 days at 23% long term mortality reduction in STEMIterm mortality reduction in STEMIApproximate 13% reduction in risk of progression to Approximate 13% reduction in risk of progression to MI in patients with threatening or evolving MI MI in patients with threatening or evolving MI symptomssymptomsBe aware of contraindications (CHF, Heart block, Be aware of contraindications (CHF, Heart block, Hypotension)Hypotension)Reassess for therapy as contraindications resolveReassess for therapy as contraindications resolve

ACE-Inhibitors / ARBACE-Inhibitors / ARB (class I, level A)(class I, level A)Start in patients with anterior MI, pulmonary Start in patients with anterior MI, pulmonary congestion, LVEF < 40% in absence of congestion, LVEF < 40% in absence of contraindication/hypotensioncontraindication/hypotensionStart in first 24 hoursStart in first 24 hoursARB as substitute for patients unable to use ACE-IARB as substitute for patients unable to use ACE-I

HeparinHeparin (class I, level C to class IIa, level C) (class I, level C to class IIa, level C)– LMWH or UFHLMWH or UFH (max 4000u bolus, 1000u/hr)(max 4000u bolus, 1000u/hr)

Indirect inhibitor of thrombinIndirect inhibitor of thrombin less supporting evidence of benefit in era of reperfusionless supporting evidence of benefit in era of reperfusionAdjunct to surgical revascularization and thrombolytic / Adjunct to surgical revascularization and thrombolytic / PCI reperfusionPCI reperfusion24-48 hours of treatment24-48 hours of treatmentCoordinate with PCI team (UFH preferred)Coordinate with PCI team (UFH preferred)Used in combo with aspirin and/or other platelet inhibitorsUsed in combo with aspirin and/or other platelet inhibitorsChanging from one to the other not recommendedChanging from one to the other not recommended

Additional medication therapyAdditional medication therapyClopidodrelClopidodrel (class I, level B)(class I, level B)

Irreversible inhibition of platelet aggregationIrreversible inhibition of platelet aggregationUsed in support of cath / PCI intervention or if Used in support of cath / PCI intervention or if unable to take aspirinunable to take aspirin3 to 12 month duration depending on scenario 3 to 12 month duration depending on scenario

Glycoprotein IIb/IIIa inhibitorsGlycoprotein IIb/IIIa inhibitors (class IIa, level B)(class IIa, level B)

Inhibition of platelet aggregation at final Inhibition of platelet aggregation at final common pathwaycommon pathwayIn support of PCI intervention as early as In support of PCI intervention as early as possible prior to PCIpossible prior to PCI

Additional medication therapyAdditional medication therapy

Aldosterone blockersAldosterone blockers (class I, level A) (class I, level A)

– Post-STEMI patients Post-STEMI patients no significant renal failure (cr < 2.5 men or 2.0 for no significant renal failure (cr < 2.5 men or 2.0 for women)women)No hyperkalemis > 5.0No hyperkalemis > 5.0LVEF < 40%LVEF < 40%Symptomatic CHF or DMSymptomatic CHF or DM

STEMI care CCUSTEMI care CCU

Monitor for complications: Monitor for complications: recurrent ischemia, cardiogenic shock, ICH, arrhythmiasrecurrent ischemia, cardiogenic shock, ICH, arrhythmias

Review guidelines for specific management of Review guidelines for specific management of complications & other specific clinical complications & other specific clinical scenariosscenarios

PCI after fibrinolysis, emergent CABG, etc…PCI after fibrinolysis, emergent CABG, etc…

Decision making for risk stratification at Decision making for risk stratification at hospital discharge hospital discharge and/orand/or need for CABG need for CABG

Unstable angina/NSTEMI Unstable angina/NSTEMI cardiac carecardiac care

Evaluate for conservative vs. invasive Evaluate for conservative vs. invasive therapy based upon:therapy based upon:

Risk of actual ACSRisk of actual ACSTIMI risk scoreTIMI risk scoreACS risk categories per AHA guidelinesACS risk categories per AHA guidelines

LowLowIntermediateIntermediate

HighHigh

Assessment Findings indicating HIGH likelihood of ACS

Findings indicating INTERMEDIATE likelihood of ACS in absence of high-likelihood findings

Findings indicating LOW likelihood of ACS in absence of high- or intermediate-likelihood findings

History Chest or left arm pain or discomfort as chief symptomReproduction of previous documented anginaKnown history of coronary artery disease, including myocardial infarction

Chest or left arm pain or discomfort as chief symptomAge > 50 years

Probable ischemic symptomsRecent cocaine use

Physical examination

New transient mitral regurgitation, hypotension, diaphoresis, pulmonary edema or rales

Extracardiac vascular disease

Chest discomfort reproduced by palpation

ECG New or presumably new transient ST-segment deviation (> 0.05 mV) or T-wave inversion (> 0.2 mV) with symptoms

Fixed Q wavesAbnormal ST segments or T waves not documented to be new

T-wave flattening or inversion of T waves in leads with dominant R wavesNormal ECG

Serum cardiac markers

Elevated cardiac troponin T or I, or elevated CK-MB

Normal Normal

Risk Stratification to Determine the Likelihood of Acute Coronary Syndrome

TIMI Risk ScorePredicts risk of death, new/recurrent MI, need for urgent

revascularization within 14 days

ACS risk criteriaACS risk criteria

Low Risk ACSNo intermediate or high risk factors

<10 minutes rest pain

Non-diagnositic ECG

Non-elevated cardiac markers

Age < 70 years

Intermediate Risk ACS

Moderate to high likelihood of CAD

>10 minutes rest pain, now resolved

T-wave inversion > 2mm

Slightly elevated cardiac markers

High Risk ACSElevated cardiac markersNew or presumed new ST depressionRecurrent ischemia despite therapyRecurrent ischemia with heart failureHigh risk findings on non-invasive stress testDepressed systolic left ventricular functionHemodynamic instabilitySustained Ventricular tachycardiaPCI with 6 monthsPrior Bypass surgery

Low risk

High risk

ConservaConservative tive

therapytherapy

Invasive Invasive therapytherapy

Chest Pain Chest Pain centercenter

Intermediate risk

Invasive therapy option Invasive therapy option UA/NSTEMIUA/NSTEMI

Coronary angiography and revascularization within 12 to 48 hours after presentation to EDFor high risk ACS (class I, level A)MONA + BAH (UFH)

Clopidogrel– 20% reduction death/MI/Stroke – CURE trial– 1 month minimum duration and possibly up to 9 months1 month minimum duration and possibly up to 9 months

Glycoprotein IIb/IIIa inhibitorsGlycoprotein IIb/IIIa inhibitors

Conservative Therapy for Conservative Therapy for UA/NSTEMIUA/NSTEMI

Early revascularization or PCI Early revascularization or PCI notnot planned plannedMONA + BAMONA + BAHH (LMW or UFH)(LMW or UFH)

ClopidogrelClopidogrelGlycoprotein IIb/IIIa inhibitorsGlycoprotein IIb/IIIa inhibitors– Only in certain circumstances (planning PCI, elevated Only in certain circumstances (planning PCI, elevated

TnI/T)TnI/T)

Surveillence in hospitalSurveillence in hospital– Serial ECGsSerial ECGs– Serial MarkersSerial Markers

Secondary PreventionSecondary Prevention

DiseaseDisease– HTN, DM, HLPHTN, DM, HLP

BehavioralBehavioral– smoking, diet, physical activity, weightsmoking, diet, physical activity, weight

Cognitive Cognitive – Education, cardiac rehab programEducation, cardiac rehab program

Secondary PreventionSecondary Preventiondisease managementdisease management

Blood PressureBlood Pressure– Goals < 140/90 or <130/80 in DM /CKDGoals < 140/90 or <130/80 in DM /CKD– Maximize use of beta-blockers & ACE-IMaximize use of beta-blockers & ACE-I

LipidsLipids– LDL < 100 (70) ; TG < 200LDL < 100 (70) ; TG < 200– Maximize use of statins; consider fibrates/niacin Maximize use of statins; consider fibrates/niacin

first line for TG>500; consider omega-3 fatty acidsfirst line for TG>500; consider omega-3 fatty acids

DiabetesDiabetes– A1c < 7%A1c < 7%

Secondary preventionSecondary preventionbehavioral interventionbehavioral intervention

Smoking cessationSmoking cessation– Cessation-class, meds, counselingCessation-class, meds, counseling

Physical ActivityPhysical Activity– Goal 30 - 60 minutes dailyGoal 30 - 60 minutes daily– Risk assessment prior to initiationRisk assessment prior to initiation

DietDiet– DASH diet, fiber, omega-3 fatty acidsDASH diet, fiber, omega-3 fatty acids– <7% total calories from saturated fats<7% total calories from saturated fats

Thinking outside the box…Thinking outside the box…

Secondary preventionSecondary preventioncognitivecognitive

Patient educationPatient education– In-hospital – discharge –outpatient In-hospital – discharge –outpatient

clinic/rehabclinic/rehab

Monitor psychosocial impactMonitor psychosocial impact– Depression/anxiety assessment & treatmentDepression/anxiety assessment & treatment– Social support systemSocial support system

Medication Checklist Medication Checklist after ACSafter ACS

Antiplatelet agentAntiplatelet agent– AspirinAspirin** and/or Clopidorgrel and/or Clopidorgrel

Lipid lowering agentLipid lowering agent– StatinStatin**– Fibrate / Niacin / Omega-3 Fibrate / Niacin / Omega-3

Antihypertensive agentAntihypertensive agent– Beta blockerBeta blocker**– ACE-IACE-I**/ARB/ARB– Aldactone Aldactone (as appropriate)(as appropriate)

Prevention news…Prevention news…From 1994 to 2004 the death

rate from coronary heart disease declined 33%... But the actual number of

deaths declined only 18% Getting better with

treatment…But more patients developing

disease –need for primary prevention focus

SummarySummaryACS includes UA, NSTEMI, and STEMIACS includes UA, NSTEMI, and STEMI

Management guideline focusManagement guideline focus– Immediate assessment/intervention Immediate assessment/intervention (MONA+BAH)(MONA+BAH)– Risk stratification Risk stratification (UA/NSTEMI vs. STEMI)(UA/NSTEMI vs. STEMI)– RAPID reperfusion for STEMI RAPID reperfusion for STEMI (PCI vs. (PCI vs.

Thrombolytics)Thrombolytics)– Conservative vs Invasive therapy for Conservative vs Invasive therapy for

UA/NSTEMIUA/NSTEMI

Aggressive attention to secondary Aggressive attention to secondary prevention initiatives for ACS patients prevention initiatives for ACS patients

Beta blocker, ASA, ACE-I, StatinBeta blocker, ASA, ACE-I, Statin

Thank You!Thank You!